Medically Indicated Deliveries Before 39 weeks

Medically Indicated Deliveries Before 39

Weeks Gestational Age

“MIDB39 weeks”

Chukwuma I. Onyeije, M.D.Chukwuma I. Onyeije, M.D.

Atlanta Perinatal AssociatesAtlanta Perinatal Associates11

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Research and Experience Show:

Early ELECTIVE delivery without MEDICAL or OBSTETRICAL indication is linked to neonatal morbidities with NO benefit for the mother or infant.

HOWEVER….

There are numerous maternal and fetal indications for deliveries BEFORE 39 weeks gestation

ALSO…

Elective deliveries AFTER 39 weeks are not necessarily without risks for mother and infant.

Is there really a problem here?

“What’s the big deal?”

“It’s only a couple of days?”

“No one is going to tell me how to practice medicine.”

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Actual quotes from OBGYN providers regarding 39 week policy. Circa 2002.

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Inductions of LaborInductions of Labor

• ACOG has cautioned against inductions before 39 weeks in the absence of a medical indication since 1979. (Committee Opinion #22)

• ACOG also suggests that “a mature fetal lung maturity test result before 39 weeks of gestation, in the absence of appropriate clinical circumstances, is NOT an indication for delivery”

(Committee Practice Bulletins #97 and #107)

How did we get here?

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1992To 2002“The Lost Decade”

Change in Distribution of Births by Gestational Age: United States, 1990-2006

Martin JA, Hamilton BE, Sutton PD, Ventura SJ, et al. Births: Final data for 2006. National vital statistics reports; vol 57 no 7. Hyattsville, MD: National Center for Health Statistics. 2009.

U.S. Cesarean Section and Labor Induction Rates Among Singleton Live Births by Week of Gestation, 1992 and 2002

Source: NCHS, Final Natality Data, Prepared by March of Dimes Perinatal Data Center, April 2006.

Gestational Age (week)

2002 Induction

2002 C-S

1992 C-S

1992 Induction

Ear

ly T

erm

Per

cen

t o

f S

ing

leto

n L

ive

Bir

ths

(%)

Rates of Induction of Labor in Singleton Births by Race and Hispanic Origin in the U.S.

Martin JA, Hamilton BE, Sutton PD, Ventura SJ, et al. Births: Final data for 2006. National vital statistics reports; vol 57 no 7.Hyattsville, MD: National Center for Health Statistics. 2009.

04/11/23Davidoff et al Sem Perinatology 2006

Per

cent

Sin

glet

on L

ive

Birt

hsChanging Distribution of US Live Births 1992 - 2002

Why are Non-medically Indicated (Elective) Deliveries

Increasing in Frequency?

Obstet Gynecol 2009;114:1254

The Gestational Age that Women Considered a Baby to be Full Term


3.3%3.3%

17.4%

21.7%

29.1%

4.8%

20.8%

The Gestational Age that Women Considered it Safe to Deliver

34 35 36 37 38 39 400%

5%

10%

15%

20%

25%

30%

35%

14%

7%

31%

22%

19%

3% 4%

Weeks of Gestation

Wom

en's

Resp

onse

s


Weeks of Gestation

Pressure on Obstetricians

Clin Obstet Gynecol 2006;49:698-704

Reasons that physicians may resist elimination of elective deliveries < 39 weeks:

•Physician Convenience• Guarantee attendance at birth

(“co-dependency”)

• Avoid scheduling conflicts

• Reduce being awakened at night

•…what’s the harm?• Bad outcomes are unrecognized and rare

• The NICU handles these issues just fine

•Limit risk of a bad pregnancy outcome

Risks of Non-medically Indicated (Elective) Delivery

Before 39 Weeks

Complications of Non-medically Indicated (Elective) Deliveries Between 37 and 39 Weeks

Clark 2009, Madar 1999, Morrison 1995, Sutton 2001, Hook 1997

• Increased NICU admissions• Increased transient tachypnea of the newborn (TTN)• Increased respiratory distress syndrome (RDS) • Increased ventilator support• Increased suspected or proven sepsis• Increased newborn feeding problems and other transition

issues

QUESTION: WHO (EXACTLY) IS TERM?

1818

1919

OLD Terminology

Modified from Drawing courtesy of William Engle, MD, Indiana University

Raju TNK. Pediatrics, 2006;118 1207.

First day of LMP

0Week # 37 0/7 416/7

Preterm Term Post term

340/720 0/7 39 0/7

Late Preterm Early Term

2020October 31, 2013

NEW Terminology

Term Pregnancy Redefined byACOG and SMFM

Published in the November 2013 Green Journal.

Four new definitions of “term pregnancy” were issued by ACOG & SMFM in a joint Committee Opinion.

Terminology designed to put the focus on preventing deliveries before 39 weeks’ gestation.

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ACOG and SMFM now discourage the use of the general label “term pregnancy”

Early Term:Between

37 weeks 0 days and 38 weeks 6 days

Full Term:Between


Late Term:Between


Postterm:Between

42 weeks 0 days and beyond

2222

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Okay. How do I know if my patient is “Full Term”?

Confirmation of Term Gestation

• Early ultrasound (< 20 weeks gestation) is more accurate than an ultrasound after 20 weeks gestation at determining gestational age and benchmarking < 39 weeks gestation.

• Ultrasound-established dates should take precedence over LMP-established dates when the discrepancy is greater than 7 days in the first trimester and 10 days in the second trimester… OR if the LMP-established dates are uncertain.

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Actual Case:

JT presented for prenatal care on 9/7/13 with an LMP of 2/19/13. She was assigned an EDD of 11/26/13 and an EGA of 28 weeks.

Her first ultrasound on 9/25/13 showed an EFW which placed her fetus at < 10 %tile.

Her second ultrasound on 10/28/13 showed an EFW which placed her fetus at < 10 %tile.

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At the time of her second ultrasound the physician performing the ultrasound asked if she had had any previous ultrasounds.

She pulled this out of her pocket from an emergency room visit on 5/23/13 (almost 5 months earlier) for spotting……

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Date performed:5/23/13

CRL: 49.5 mm

EGA: 11w5d

Emergency Room Ultrasound

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NEW EDD: 12/7/13

NEW EFW %tile: 54%

Induction / Cesarean Scheduling Process

Induction / Cesarean Scheduling Process

Physician Leadership A. Enforce policy B. Approve exceptions

Physician Leadership A. Enforce policy B. Approve exceptions

Clinician and/or Patient Desire to Schedule a Non-medically

Indicated (Elective) Induction or Cesarean Section

Clinician and/or Patient Desire to Schedule a Non-medically

Indicated (Elective) Induction or Cesarean Section

Case NOT Scheduled if Criteria Not Met

Case NOT Scheduled if Criteria Not Met

Elective Delivery Hospital Policy

Elective Delivery Hospital Policy

Clinician, Staff & Patient EducationClinician, Staff &

Patient Education Reduce Demand

QI Data Collection & Trend Charts

QI Data Collection & Trend Charts

Public Awareness Campaign

Public Awareness Campaign

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3131

Okay. Okay. Let’s get Let’s get

real.real.

Not all deliveries before 39 weeks Not all deliveries before 39 weeks are for “convenience”.are for “convenience”.

Timing of Indicated Late-Preterm and Early-Term Birth.Obstetrics & Gynecology. 118(2, Part 1):323-333, August 2011.

ACOG Committee Opinion: April 2013

3333Medically indicated late-preterm and early-term deliveries. Committee Opinion No. 560. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:908–10.


The neonatal risks of late preterm and early-term births are well established.

HOWEVER, there are a number of complications in which either a late-preterm or early-term delivery is warranted.

The timing of delivery must balance the maternal and newborn risks of late-preterm and early-term delivery with the risks of further continuation of pregnancy.

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Decisions regarding timing of delivery must be individualized.

Amniocentesis for the determination of fetal lung maturity in well-dated pregnancies generally should not be used to guide the timing of delivery.

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Terminology Recall….

3636

Early Term:Between


Full Term:Between


Late Term:Between


Postterm:Between


Terminology for Medically Indicated Deliveries

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Late PretermBetween 34 weeks 0 days and

36 weeks 6 days.

Early Term:Between


Full Term:Between


Late Term:Between


Postterm:Between


Categories for Medically Indicated Deliveries:

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Placental / Uterine Issues

Condition General Timing Suggested Specific Timing

PLACENTA PREVIA LATE PRETERM/EARLY TERM36 0/7 to 37 6/7

WEEKS OF GESTATION

PLACENTA PREVIA WITH SUSPECTED ACCRETA, INCRETA, OR

PERCRETA LATE PRETERM 34 0/7 to 35 6/7 WEEKS OF GESTATION

PRIOR CLASSICAL CESAREAN LATE PRETERM/EARLY TERM 36 0/7 to 37 6/7 WEEKS OF GESTATION

PRIOR MYOMECTOMY EARLY TERM/TERM (INDIVIDUALIZE)

37 0/7 to 38 6/7 WEEKS OF GESTATION


GROWTH RESTRICTION (SINGLETON)

Fetal issues


OTHERWISE UNCOMPLICATED, NO CONCURRENT FINDINGS EARLY TERM / TERM 38 0/7 to 39 6/7

WEEKS OF GESTATION

CONCURRENT CONDITIONS

(OLIGOHYDRAMNIOS, ABNORMALDOPPLER STUDIES, MATERNAL CO-

MORBIDITY (IE, PREECLAMPSIA, CHRONIC HYPERTENSION)

LATE PRETERM / EARLY TERM 34 0/7 to 37 6/7 WEEKS OF GESTATION


GROWTH RESTRICTION (TWINS)FETAL ISSUES:


Di – Di TWINS WITH ISOLATED FETAL GROWTH

RESTRICTIONLATE PRETERM/EARLY TERM 36w 7d 37w 6d

GESTATION

Di – Di TWINS WITH CONCURRENT CONDITIONS LATE PRETERM 32w 7d 34w 6d

GESTATION

Mono – Di TWINS WITH ISOLATED FETAL GROWTH

RESTRICTIONLATE PRETERM 32w 7d 34w 6d

GESTATION

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MULTIPLE GESTATIONS

FETAL ISSUES:


Di – Di TWINS EARLY TERM38w 0d

38w 6dGESTATION

Mono - Di TWINS LATE PRETERM/EARLY TERM

34w 7d 37w 6d

WEEKS OF GESTATION


OLIGOHYDRAMNIOS

FETAL ISSUES:


OLIGOHYDRAMNIOS LATE PRETERM EARLY TERM

36w 0d 37w 6d

GESTATION


HYPERTENSIVE DISORDERS

MATERNAL INDICATIONS

CONTROLLED & NO MEDICATIONS EARLY TERM/TERM

38w 0d 39w 6dGESTATION

CONTROLLED ON MEDICATIONS EARLY TERM/TERM


DIFFICULT TO CONTROLLATE PRETERM/EARLY

TERM36w 0d 37w 6d

GESTATION

GESTATIONAL HYPERTENSIONEARLY TERM


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HYPERTENSIVE DISORDERS(Preeclampsia)

MATERNAL INDICATIONS

SEVERE PREECLAMPSIA LATE PRETERMAT DIAGNOSIS AFTER 34w 0d GESTATION***

MILD PREECLAMPSIA EARLY TERM

AT DIAGNOSIS AFTER 37w 0d

GESTATION

4848*** Clinical judgment important

DIABETES

MATERNAL INDICATIONSPREGESTATIONAL: WELL-CONTROLLED* LATE PRETERM, EARLY TERM BIRTH NOT INDICATED

PREGESTATIONAL WITH VASCULAR COMPLICATIONS

EARLY TERM / TERM 37w 0d 39w 6d GESTATION

PREGESTATIONAL:POORLY CONTROLLED

LATE PRETERM OR EARLY TERM

INDIVIDUALIZED

GESTATIONAL:WELL CONTROLLED ON DIET OR MEDICATIONS

LATE PRETERM, EARLY TERM BIRTH NOT INDICATED

GESTATIONAL:POORLY CONTROLLED

LATE PRETERM OR EARLY TERM

INDIVIDUALIZED4949

PREMATURE RUPTURE OF MEMBRANES (PROM)

OBSTETRICAL INDICATIONS

PPROM LATE PRETERM 34w 0d GESTATION

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Conclusion:Reasons to Eliminate Non-Medically

Indicated (Elective) Deliveries Before 39 Weeks

Reduction of neonatal complications

No harm to mother if no medical or obstetrical indication for delivery

Strong support from ACOG

Now a national quality measure for hospital performance:- National Quality Forum (NQF)

- Leapfrog Group

- The Joint Commission (TJC)5252

04/11/2304/11/23

HOW AM I GOING TO REMEMBER ALL OF THIS?

• These are guidelines. Clinical judgement and common sense should come first.

• This presentation is available online.• http://bit.ly/midb39

• There’s an app for this.http://bit.ly/midb39app OR

• http://bit.ly/midb39play

04/11/2304/11/23

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Medically Indicated Deliveries Before 39 weeks

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